Callagy Law Arizona: medical providers

Showing posts with label medical providers. Show all posts

Monday, March 14, 2016

“A personal and professional perspective from an employee of Callagy Law” – Mark H. Winters, Jr., paralegal

The purpose of this post is to help assist those with questions they have concerning their business or medical practice. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. We hope to have this blog shed a light on many common questions.

Personally, the field of PIP represents a step in my career that allows me to take part in something important, something helpful, and something that can help work within a broken system for the greater good. Professionally, working in PIP at Callagy Law has exposed me to some of the brightest attorneys, who quite frankly I feel have revolutionized arbitration on a number of pertinent issues, all without cost to the clients.

In explanation of my enthusiasm in PIP, it is relevant that the first eight (8) years of my legal career I was involved largely in consumer collections litigation, a particularly dreary aspect of law. Spending so much time in that field, it begins to cloud your overall perspective on the very nature of law, people, and even yourself. Luckily, in June 2014, I took the opportunity to work in the PIP department at Callagy Law.

Now, at first, I was not even clear on what working in PIP would mean, or if anything could improve my jaded outlook of the law. However, integrating myself into the world of PIP was almost therapeutic. This was an opportunity to do something good, for the first time in my career representing the “good guys,” and it was exiting to find that the remainder of Callagy Law was likewise enthused. For, after all, who does it feel better to help than those who dedicate their lives to helping others?

Notably, in PIP we get to represent a huge variety of doctors and institutions, each of whom are essential for an immeasurable amount of car accident victims. Throughout the days and weeks, we handle cases involving everything from initial Hospital Emergency Room visits, to the initial stages of treatment (ie. chiropractic, physical therapy), then moving along to more advanced and complicated treatment providers, including specialized dental practitioners, pain management physicians. Whether it is underpayment of services, or an outright denial of necessary treatment, we argue on behalf of the treating doctors, who typically provide the patient with the necessary care even at the risk of insurance denials. It is here that my job comes in, helping those doctors get payment for the services they rendered to their patients in good faith.

In fact, one thing I did not know before starting in PIP, and what actually may make Callagy Law unique among PIP practitioners, is that we even represents pharmacies who issue prescribed medications that insurance companies nevertheless fail to pay for. I have even seen reimbursements awarded to psychologists and counselors whose post-traumatic stress therapies are denied prematurely. So, yes, I found that even such apparently ancillary providers such as pharmacies, dentists, and psychologists can benefit from an attorney’s PIP services.

In short, while I was feeling quite negative about the field and practice of law before starting in PIP, working for the benefit of the medical field to encourage fair payment, and in recovering the amounts unjustly denied, means something to me, to this firm, and, I like to think, our clients as well.

We hope you have found this information helpful and interesting. Please reach out to us here with any questions or comments regarding healthcare legal matters, or if you are a medical provider that has questions regarding Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Tuesday, February 2, 2016

New Rule Medical Providers Will Like | Callagy Law

DOBI HAS PROPOSED A NEW RULE AT NJAC 11:3-4.7B TO ESTABLISH UNIFORM APPEAL PROCEDURES THAT WE THINK MEDICAL PROVIDERS WILL LIKE

The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

On November 2, 2015, the New Jersey Department of Banking of Insurance (“Hereinafter “DOBI”) proposed amendments to certain current and pending regulations relating to the Internal Appeals procedures medical providers were required to comply with when faced with PIP denials. Under the old regulations and prior pending regulations, medical providers were required to strictly follow the specific procedures set forth in each insurance carrier’s (Hereinafter “Carrier”) Decision Point Review Plan in order in order to appeal.

As every medical provider, and every PIP attorney well knows, internal appeal procedures vary widely by both Carrier, and by type of appeal – meaning there is one set of procedures when appealing pre-service denials, such as precertification, and another set of procedures when appealing post-service denials, such as non-payment or under-payments. The only requirement placed upon the Carrier was that their internal appeals process must be published in its DOBI approved Decision Point Review Plan.

Also contained within these procedures are certain critical deadlines, which vary widely by Carrier. For example, one Carrier may require that any post service appeal be filed within 30 days of the denial, but require that any pre-service denial be appealed within ten days. Another Carrier may require pre-service denials to be appealed with 15 days but post service appeals be appealed within ten days. Keeping track of these deadlines on behalf of every Carrier can be quite complicated for the medical provider, yet it can become quite costly if they don’t.

Moreover, some Carriers impose a 2 level post-service appeal process while some require just one. Each level has their own unique timeline, as well. Further, some Carriers require that a first level appeal must be faxed to one number while second level appeals must be faxed to an entirely separate fax number. One Carrier even recently changed their requirements such that its first level appeal was required to be faxed to its 3^rd party administrator, but its 2^nd level appeal process required the medical provider to mail their appeal via certified mail only, with return receipt requested! Considering substantial supporting documentation is often required and included in a second level appeal, the size and cost of such a requirement imposed on the provider was quite burdensome.

Fortunately, in this most recent proposal, DOBI recognized that the varying internal appeals processes made it “complicated and burdensome” for providers to appeal and is now proposing to repeal and replace the current internal appeals process in its entirety.

In its place, DOBI is now proposing a uniform internal appeals process which must be adopted by all Carriers. [SEE IT HERE www.state.nj.us/dobi/proposed/prn09_207.pdf ]

The most significant changes for the medical provider in this latest proposal by DOBI include:

A uniform appeal form;

Carriers will be limited to one level of appeal only;

Uniform critical deadlines; pre-service appeals must be submitted within 30 days of the denial and Carriers must respond within 14 days, post service appeals must be submitted 45 days prior to initiating dispute resolution and Carriers will have 30 days to respond;

A clear definition of what constitutes a pre-service appeal and what constitutes a post-service appeal.

By and large, these changes are most welcome to the medical provider. Medical providers are well aware that, in addition to being complicated and burdensome, Carriers have repeatedly wielded the internal appeals process against the medical provider as a threshold weapon in arbitration. Compliance with a particular Carrier’s internal appeals process created a very fertile ground in the arbitration arena for a Carrier to argue that any variance, no matter how minor, forecloses the medical provider from ever being reimbursed for its services. The question of medical necessity is never reached. This defied the very purpose of internal appeals, which were instituted to provide a Carrier the opportunity to take a second look at a denial prior to being required to engage in costly arbitration or litigation.

Now however, should these proposed regulations be adopted, the internal appeals process will be uniform and simplified. Of course, arbitrators will continue to strictly enforce the regulations, but it appears the field will finally be leveled for the medical provider.

The Team at Callagy Law hopes the information in this article was helpful in either your personal or professional life. The legal world pertains to all walks of life and more specifically, various types of healthcare providers. Callagy Law, is a multidisciplinary law firm, headquartered in Paramus, NJ owned and operated by Sean Callagy. We are committed to providing legal representation and advice to our clients at additional law offices located across the United States. Please note that the information posted here should not be used as a legal argument of defense. If you find yourself needing legal advice pertaining to your unique situation, you can contact us at here. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

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New Rule Medical Providers Will Like | Callagy Law

Wednesday, January 27, 2016

Medical Provider Applications In New Jersey Workers’ Compensation Courts

The Effect of the 2012 Amendment

The New Jersey Workers’ Compensation courts provide a forum for healthcare providers to challenge inadequate reimbursements from workers’ compensation insurance carriers where the underlying claim is for a patient injured within the course of their employment. It was not until 2012 that the New Jersey Workers’ Compensation courts gained exclusive jurisdiction over these types of claims. The majority of cases that are filed in the Workers’ Compensation courts involve the injured worker’s (i.e. Petitioner) claim against his/her employer’s workers’ compensation insurance carrier (Respondent).

The 2012 Amendment to N.J.S.A. 34:15-15 effected a significant change in the rights of medical providers who have provided authorized treatment to injured workers in New Jersey. As a recent addition to the Workers’ Compensation Act, however, the language of the Amendment has not been interpreted in any prior decision in New Jersey. The full text of the Amendment provides:

Fees for treatments or medical services that have been authorized by the employer or its carrier or its third party administrator or determined by the Division of Workers’ Compensation to be the responsibility of the employer, its carrier or third party administrator, or have been paid by the employer, its carrier or third party administrator pursuant to the workers’ compensation law, R.S.34:15-1 et seq., shall not be charged against or collectible from the injured worker. Exclusive jurisdiction for any disputed medical charge arising from any claim for compensation for a work-related injury or illness shall be vested in the division. The treatment of an injured worker or the payment of workers’ compensation to an injured worker or dependent of an injured or deceased worker shall not be delayed because of a claim by a medical provider.

N.J.S.A. 34:15-15.

Prior to this Amendment, the state of the law in New Jersey with respect to medical provider claims in workers compensation matters was extensively reviewed by the New Jersey Supreme Court in Univ. of Mass. Mem’l Med. Ctr., Inc. v. Christodoulou, 180 N.J. 334 (2004). As discussed in Christodoulou, while the Workers Compensation Act with limited exceptions provides an exclusive remedy to employees injured the course of their employment, the Act “does not purport to establish an exclusive remedy for a hospital or physician that, pursuant to a contract, has provided medical services to a patient who may or may not have suffered a job-related injury.” Id. at 346. Thus, medical providers asserting claims arising from treatment provided to injured workers previously had the option to pursue their claims either in the Division of Workers Compensation, as authorized by N.J.S.A. 34:15-15, or in a common law collection action in Superior Court. Id. at 353. If a claim by a medical provider was asserted in Superior Court while a related claim by an injured worker was pending in the Division, the medical provider action was to be transferred to the Division to facilitate the resolution of all claims in a single forum. Id. at 352.

The 2012 Amendment to N.J.S.A. 34:15-15 changed existing law by vesting exclusive jurisdiction for any disputed medical charge arising from any claim for compensation in the Division, thus eliminating the option to pursue a common law collection action in Superior Court. The 2012 Amendment also changed existing law by providing that fees for treatments authorized by a workers’ compensation carrier shall not be charged against or collectible from the injured worker. Prior to the 2012 amendment, there was no statutory prohibition against a medical provider asserting its common law contractual right to payment for services provided. In the event the workers compensation carrier failed to make payment, or as is more common, made only a partial payment, and the petitioner settled its compensation claim without providing for payment of outstanding medical bills, the petitioner was exposed to potential liability for the balance. The 2012 amendment eliminated the practice of “balance billing” by requiring the medical provider to seek payment exclusively from the workers compensation carrier, with no contribution from the employee. With respect to medical provider claims covered by the 2012 Amendment, the statute thus significantly altered the medical provider’s rights by making a claim against the employer and its workers compensation carrier in the Division pursuant to N.J.S.A. 34:15-15 the exclusive remedy of the medical provider, supplanting its right to pursue its common law remedies in Superior Court.

Learning from others and seeking to find information is the first step to success. Whether you need questions answered about Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance., Callagy Law is here to assist you every step of the way. We are headquartered in Paramus, NJ and we are full service law firm that specializes in serving businesses, healthcare providers and individuals. Sean Callagy has assembled a team of attorneys that are exceptional leaders in their legal expertise and have been commended for providing exceptional legal services at every level. If you need a true hands of experience with a legal team, feel free to contact us at here and come meet with Sean Callagy himself. There is no substitute when it comes to working with a lawyer and law team that cares deeply about their clients. Feel free to search us on Facebook, Twitter or LinkedIn!

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Medical Provider Applications In New Jersey Workers’ Compensation Courts

Tuesday, December 22, 2015

Reimbursement Under New Jersey PIP laws | Callagy Law

When does UCR (the usual, customary and reasonable amount) apply?

The purpose of this post is to help assist healthcare providers and the public with questions they have concerning topics related to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. The Callagy Law team is knowledgeable in all aspects of these sorts of legal matters and will frequently post topics in this field. We hope to have this article shine a light on many common questions.

Medical providers may wonder why a PIP insurance company pays less than the amount billed. For example, perhaps a north region doctor bills $200.00 for an office visit billed under CPT Code 99214. The PIP insurer reimbursed the doctor $125.71. Is a balance due? The general answer is no, and that is because a medical fee schedule governs the reimbursement for this treatment. Other times, however, there may not be a medical fee schedule at all. What is the standard of reimbursement in that instance?

To determine the proper amount due, a review of the New Jersey PIP reimbursement structure is in order. This discussion concerns reimbursement amounts, not whether PIP benefits apply in the first place. Other issues, such as medical necessity and causality, factor into such right to reimbursement.

As to the amounts due, it must be recognized the Department of Insurance and Banking (“DOBI”) has promulgated many medical fee schedules. These payment schedules cover a variety of types of medical providers, as well as a wide array of CPT Codes. A summary of these fee schedules may be found at http://www.state.nj.us/dobi/pipinfo/aicrapg.htm.

Therefore, the first step is to review the fee schedules listed on the DOBI website and see if the type of medical provider and CPT Code for the treatment is listed. Also, there are times a medical fee schedule may not apply. For example, if a trauma doctor provides trauma services and bills with a –TS modifier, the fee schedule amount will not apply, but rather, a UCR standard applies. N.J.A.C. 11:3-29.2 defines trauma services as follows:

“Trauma services” means the care provided in the Level I or Level II trauma hospital to patients whose arrival requires trauma center activation. It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activation or outpatient visits after a patient who has received trauma care is discharged from acute care.”

What is UCR? UCR is the usual, customary and reasonable amount due for treatment. How is UCR determined? The governing DOBI regulation, N.J.A.C. 11:3-29.4, provides the amount due will be that of a similar code on a medical fee schedule. If there is no similar code, UCR is determined by a process. First, the medical provider submits its customary bill. It is imperative the provider retain exemplar Explanation of Benefits showing the payment received from other payors. The PIP insurer may then determine the reasonableness of the fee by comparing its experiences with that provider and other providers in the region. The PIP carrier may also rely upon national databases of fees to determine the reasonableness of the bill for the provider’s geographic region.

Callagy Law handles many PIP arbitrations in which UCR is a significant issue. Our success generally depends upon the UCR proofs we are able to introduce at hearing. We implore our medical providers to retain copies of exemplar EOBs to show what PIP carriers are reimbursing them for treatment that is not subject to a medical fee schedule. It will help in our ability to obtain proper reimbursement at UCR if we have the supporting documents.

We hope you have found this information helpful and interesting. Please reach out to us here with any questions or comments regarding healthcare legal matters, or if you are a medical provider that has questions regarding Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Reimbursement Under New Jersey PIP laws | Callagy Law

Wednesday, December 16, 2015

Must Know Info For Medical Providers | Callagy Law

Providers Making The Most Out of Recovery

The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

Medical Providers are busy people, as are their patients. Doctors are (and should be) more preoccupied with treating their patients and increasing the quality of their lives, rather than dealing with administrative paperwork. That is why medical providers rely upon their office staff for assistance. In the hustle and bustle of day to day treatment of patients, some doctors pay less and less attention to the underlying business aspects of their practice. However, it is important that medical providers themselves stay informed as to how to optimally recover money for the treatment and procedures they provide.

Insurance carriers will deny a claim for many reasons – need for additional records, amended bills, etc. It could take over a year in some cases for a medical provider to be reimbursed. Obviously, this has a detrimental impact on a medical providers’ expected cash flow.

So what can a medical provider do to overcome these denials and delays? A medical provider should be aware which procedures are covered by the patient’s insurance policy. More information is also available on http://www.cms.gov and/or on the insurance carrier’s website. For instance, Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant, nurse practitioner or clinical nurse specialist. A medical provider should try to get pre-authorization from the insurance carrier, while also being mindful of other denial issues, such as a perceived lack of medical necessity.

If a medical provider wants to proceed on a non-covered procedure, they should be aware in advance that the insurance carrier will deny payment. If a medical provider is considering charging the patient, they should be sure to have an agreement with the patient in writing prior to surgery. Billing after surgery is not always the best business policy for medical providers and may even be in violation of a contract if they are in-network with particular insurance carriers. Moreover, balance billing the patient in most cases is not permitted in PIP (Personal Injury Protection) and Medical Provider Workers’ Compensation claims.

The medical provider should specific services he or she performs in its operative report, ensuring that every CPT code in the bill correlates with the operative report. Insurance carriers will usually reference the operative report to confirm this information and will sometimes request the assistant surgeon’s medical records. A medical provider should be prepared to get involved and file multiple appeals in order to be reimbursed.

However, the most important step in the entire process occurs in the pre-surgery stage– don’t be afraid to communicate with the insurance carriers about what documents and information they need to efficiently and effectively process the claim, what procedures are authorized, and what is the expected reimbursement rate. Be sure to thoroughly document these conversations, or better yet, get it in writing.

Of course, it is very important to hire a law firm to review claims, handle appeals and proceed to litigation, as doctors are very busy with treating their patients – which is what matters most.

We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $175,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

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Must Know Info For Medical Providers | Callagy Law

Tuesday, December 8, 2015

Hospital Anesthesia Services Potentially Recoverable! | Callagy Law

Are Hospitals Entitled to Reimbursement for anesthesia services?

Anesthesia is a way to control pain during a surgery or procedure by using medicine called anesthetics. General anesthesia is used to ensure comfort and safety during certain types of procedures. Anesthesia effects and helps control a patient’s breathing, blood pressure, blood flow, and heart rate/rhythm, among other things.

When you get general anesthesia, in layman’s terms, “put under,” you are completely unconscious and immobilized. General anesthesia may be administered via gas, an IV line or a combination of both. Typically, major/complex procedures that require a long period of time to perform require general anesthesia.

A patient may present to an Ambulatory Surgery Center (ASC) or a Hospital facility to undergo these types of major/complex procedures. In a case where a patient presents to a Hospital facility to undergo a procedure, the Hospital provides the anesthesia and necessary supplies. The hospital provides the equipment, supplies and sometimes staff required to safely and effectively deliver anesthesia services during the procedure. The specific resources that the hospital provides vary depending upon the type of anesthesia the patient requires and the patient’s particular medical condition. The staff will also vary according to the hospital. Sometimes the staff are outside anesthesiologists working in the hospital, and sometimes, they are hospital employees.

So how is this billed to the insurance carrier? In the case of the outside anesthesiologist, they will bill separately for his or her professional services, as will your surgeon and the other physicians who provide services for you while you are hospitalized. They will bill for part of the services, called the professional component. The hospital will issue a separate bill for all of the services and items the hospital provided during your hospitalization and that bill will include charges for the hospital’s role in the delivery of anesthesia services based on the specific type anesthesia services a patient receives. The hospital’s bill is for what’s called the technical or facility component.

An insurance carrier may attempt to argue that the Hospital improperly submitted what constitutes duplicate billing of anesthesia for the date(s) of service that are at issue. Usually, this is based upon the fact that the anesthesiologist, who administered the anesthesia services on the date(s) in question, had already submitted his/her independent bills for the “same” instance of anesthesia services for the procedure. This is incorrect, as both the anesthesiologist and hospital are each billing only for their portion of the services provided.

The insurance carrier may also attempt to argue that pursuant to N.J.A.C. 11:3-29.4(o)(7) anesthesia materials, including the anesthetic itself, and any materials, whether disposal or reusable, necessary for its administration are not entitled to a separate charge. As such, the Hospital facility would not be entitled to reimbursement for anesthesia because anesthesia services were “bundled” into the main surgical code. However, this is not always the case.

There are several arguments that Callagy Law has successfully advanced where arbitrators in NJ No-Fault (PIP) arbitrations have determined that such anesthesia services are separately reimbursable to the hospital. Namely, if the procedure was an inpatient procedure, if it was an emergency procedure, or if it was an outpatient surgical procedure, where the main surgical code billed was not on the Hospital Outpatient Surgical Facility (HOSF) fee schedule. In each of these examples, there are strong arguments to be made that the technical/facility portion of anesthesia should have been reimbursed to the Hospital, despite the carrier’s arguments to the contrary.

Therefore, Hospital facilities are sometimes entitled to separate reimbursement for anesthesia services in addition to the anesthesiologist’s separate and distinct bill for his/her own personal services.

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Hospital Anesthesia Services Potentially Recoverable! | Callagy Law

Friday, December 4, 2015

The Importance of Trust | Callagy Law

Helpful Hints for Gaining Client Trust and Appreciation

As with any meaningful relationship, trust between you and your client is essential. Business relationships are always best when they are for the long-term. Relationships that last help to generate repeat business and help with new relationships when happy clients refer your services to others. This is all made possible by Trust.

As a client liaison with Callagy Law, I am responsible for helping identify, assemble and pursue medical provider claims against insurance carriers. This includes PIP (No-Fault/MVA) claims, Workers Compensation (WC) claims and Commercial Insurance (CI) claims. The foundation of this relationship is a firm belief by the medical provider that I am knowledgeable, thorough, competent and responsive. Clients need to believe that I am identifying the right claims—all the right claims, I am gathering all the necessary documents, for all the relevant dates of service, and seeing the claim through to its resolution. This belief is Trust.

Trust, however, also has an emotional component. You and your client need to genuinely appreciate each other. One of the best ways to start building a long-lasting relationship with your client is by expressing your thanks and gratitude. Pick up the phone, and give them a call to express how you appreciate their business and how much they, personally, mean to you. Spending the time to communicate your gratitude with your clients goes a long way. Perhaps a phone call is not the right approach—maybe a thank you lunch, an occasional box of treats, a card on a birthday, or perhaps just being helpful and thoughtful in your interactions.

Responsiveness is also an important component. Your clients depend on you to keep them informed. It is true that we all vary in our needs and desires for information–some clients like to be informed about everything and some prefer to be told only about the more significant developments. Communicating with clients regularly puts them at ease.

Building relationships with your clients is something that takes time, patience, and effort. The result is Trust. The outcome is a profound and lasting relationship that is both meaningful and mutually beneficial.

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The Importance of Trust | Callagy Law

Tuesday, November 24, 2015

The PIP Pre-Certification Process | Callagy Law

A blog post by Stacey Hoskins, Callagy Law Paralegal

After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Do you have questions pertaining to reimbursement? Do you know what to do if problems arise? With articles written by Callagy Law’s law team, this blog will focus on many common questions and concerns surrounding legal matters which can arise in the field of healthcare law.

It is important that medical providers comply with the insurance carrier’s Pre-Certification policy. Pre-Certification is the process of notifying an insurance carrier of the treatment you plan to perform on a particular patient prior to doing so. Failure to comply can result in penalties being applied to a medical provider’s billing, which cannot be balance billed to the patient.

While a medical provider must comply with the Pre-Certification process, the insurance carrier also has requirements they are required to meet in order to assess penalties. There are also many ins and outs of the Pre-Certification process that you should be aware of and many scenarios in which penalties should not be assessed by the insurance carrier.

In many instances the insurance carrier will attempt to assess penalties in situations inappropriately, and in scenarios where they failed to comply with the requirements placed on them. Callagy Law is an expert in fighting inappropriately applied Pre-Certification penalties, and has been successful on a multitude of occasions in obtaining full refunds for our clients of incorrectly assessed penalties. Here are some examples of cases in which Callagy Law has been successful in obtaining refunds:

Improper notice of the Pre-Certification process

Each and every PIP Insurance carrier is required to establish their own specific procedures as to Pre-Certification. This information is contained in each carrier’s Decision Point Review Plan (“DPRP”). The insurance carrier must provide both the medical provider and the patient with a copy of their specific DPRP so that they are properly notified of the procedures. If the insurance carrier fails to do so, no penalties can be applied. On multiple occasions this firm has obtained a return of penalties that were inappropriately assessed wherein the DPRP plan was not properly served.

Timely response by the insurance carrier is required

Additionally, New Jersey law requires an insurance carrier to respond to a provider’s pre-certification requests within 3 business days. If the carrier fails to timely respond, they are barred from raising any medical necessity defenses to the treatment performed.

In such cases, arbitrators have held that, essentially, authority to perform the treatment was granted by insurance carrier through their failure to timely respond to a pre-certification request. In a scenario wherein no evidence has been produced to indicate that an insurance carrier timely replied to a Pre-Certification request, Callagy Law has been successful in obtaining payment in full for the services requested in Pre-Certification.

Pre-Certification penalties cannot be assessed to the 1^st 22 dates of treatment

You, as the medical provider are required to notify an insurance carrier of your treatment of a patient within 22 days of first seeing the patient.

Callagy Law has successfully advanced the argument that, as a medical provider is not required to notify the insurance carrier of that they are treating apt until the 22^nd day of treatment, there can be no pre-certification penalties applied within those first 22 days.

No Pre-Certification required for pre-admission testing

In the event that a patient’s health required pre-admission testing prior to undergoing surgery, Callagy Law has successfully advanced the argument that such testing does not require Pre-Certification and penalties cannot, therefore, be applied to these services. To delay these minor diagnostic tests to obtain for the purposes of obtaining Pre-Certification would actually be counter-productive since such Pre-Certification would have resulted in a second office visit and additional charges.

In conclusion, Pre-Certification is a technicality through which insurance carriers often attempt to improperly assess penalties to admittedly medically necessary and approved treatment. Don’t let this happen to you. Contact Callagy Law for help in obtaining refunds of the penalties that have already been incorrectly assessed to your billing.

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The PIP Pre-Certification Process | Callagy Law

Wednesday, November 11, 2015

The Importance of Pre-Authorization|Callagy Law

Denials for Assistant Surgeons

The following article was written by Callagy Law’s Legal Team and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

There is a recent trend for assistant surgeon denials by several insurance carriers. Likewise, there is a new development in insurance carriers postponing payment for these claims pending additional documentation or even separate assistant surgeon operative reports. Obviously, this has a detrimental impact on a medical providers’ expected cash flow.

So what can a medical provider do to overcome these denials and delays?

A medical provider should be aware which procedures permit the use of an assistant surgeon and are covered by the patient’s insurance policy. This information is typically available on http://www.cms.gov and/or on the insurance carrier’s website. For instance, Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant, nurse practitioner or clinical nurse specialist.

A medical provider should try to get pre-authorization from the insurance carrier for the assistant surgeon, while also being mindful of other denial issues, such as a perceived lack of medical necessity.

If a medical provider wants to have an assistant for a non-covered procedure, they should be aware in advance that the insurance carrier will deny payment. If a medical provider is considering charging the patient, they should be sure to have an agreement with the patient in writing prior to surgery. Billing after surgery is not always the best business policy for medical providers and may even be in violation of a contract if they are in-network with particular insurance carriers. Moreover, balance billing the patient in most cases is not permitted in PIP (Personal Injury Protection) and Medical Provider Workers’ Compensation claims.

The medical provider should identify the assistant surgeon and the specific services he or she performs in the primary surgeon’s operative report. Insurance carriers will usually reference the operative report to confirm this information and will sometimes request the assistant surgeon’s medical records. Assistant surgeons do not typically have separate operative reports, so if payment is delayed for this reason, be sure to point this out in your appeals.

All that being said, a medical provider should be prepared to get involved and file multiple appeals in order to be reimbursed.

However, the most important step in the entire process occurs in the pre-surgery stage– don’t be afraid to communicate with the insurance carriers about what documents and information they need to efficiently and effectively process the claim, what procedures are authorized, and what is the expected reimbursement rate. Be sure to thoroughly document these conversations, or better yet, get it in writing.

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The Importance of Pre-Authorization|Callagy Law

Friday, September 25, 2015

The Short-Term Impact of the Transition to ICD-10

On October 1, 2015, ICD-10 will go into effect, displacing ICD-9, which has been in place for 30 years. ICD-10 will introduce greater detail and therefore greater complexity to medical billing and coding practices. Indeed, In excess of 150,000 new procedure and diagnosis codes will be introduced. As a result, it is safe to say that disagreements with carriers and controversy in interpretation will be commonplace for some time to come. Because of this, medical providers need to brace themselves for what is sure to be increases in denials from carriers with a concomitant reduction in revenue. Although these denials of course can and should be challenged at every turn, medical provider cash flow in the short run will certainly be impacted.

This is especially true in light of the fact that ICD-10 is not being mandated, thus far, at the state level. Hence, PIP and WC claims can still be processed under ICD-9. This gives PIP and WC carriers perhaps an additional opportunity for denial—they might request a bill submitted under ICD-9 to be re-submitted under ICD-10 and vice versa—anything to cause delay or denial in reimbursement.

Medical providers need to be especially vigilant and aggressive in their refusal to accept these denials and delays at face value, and should prepare themselves financially for a reduction in revenue, at least in the short run.

If you have questions regarding ICD-10, or any other legal questions, please feel free to contact Callagy Law today! If you are a medical provider, please refer to our Medical Providers page on our website.

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The Short-Term Impact of the Transition to ICD-10

Friday, September 18, 2015

Pursuing Medical Debt From Insurers | Medical Revenue Recovery

Medical doctors enter medicine to practice medicine, not to be bill collectors, but running a medical practice is far from inexpensive today. From medical malpractice insurance, personnel costs, operational costs, rent, and other administrative costs, the everyday costs of running a practice can be quite high.

Also, under many laws at either the state or Federal level, as well as under insurance carrier in-network contracts with doctors, providers are required to bill patients for their portion of a bill. So, patients are expected to pay for co-pays, coinsurance, and deductibles as required under their insurance plans.

Medical doctors are required to bill patients for the patient’s portion of the cost of medical care. If a doctor does not do so, he may face legal and financial penalties from regulators and insurance carriers. For example, an insurance carrier may reduce a provider’s payment by the percentage of the payment that the provider failed to bill the patient for. For example, if the provider billed a service at $100 with the insurer paying $80 and the patient to pay $20, but the patient was never charged, then the insurer may request a reimbursement of 20% of the $80 since the insurer only agreed to pay 80% of the total bill.

ERISA

The Employee Retirement Insurance Security Act (ERISA) is a Federal law that establishes minimum standards for employer-sponsored retirement plans as well as health insurance plans. While ERISA puts many requirements on employers regarding how they administer plans for their employees, providers may also be subject to ERISA.

Under ERISA health care plans, employers must provide their employees with health insurance plan information. As such, employees are expected to know and adhere to their responsibilities in paying for their share of the medical bill, such as coinsurance, copays, or deductibles.

Alternatively, insurance carriers representing employers are required to follow certain notice and disclosure rules in working with providers in providing reimbursements. Insurance carriers must be open and transparent about their policies and payment decisions under ERISA plans. In other words, insurers cannot simply deny claims or dramatically underpay claims without a reasonable explanation.

State Prompt Pay Laws

Some states, including New York, have prompt pay laws. Under prompt pay laws, insurance carriers are required to pay “clean claims” (medical claims from providers without any missing or incorrect information) within a certain number of days, such as 45 days. So, if insurers are dragging their feet on claims by neither approving or denying them then they may be violating state law. As a result, it may be necessary for a provider to reach out to the state insurance commission, or similar agency, and file a complaint. Doing so may push the insurance carrier to improve their processes and pay in accordance with the law.

Contact a Knowledgeable Law Firm for Guidance

Creating and maintaining a business can be a daunting endeavor. The experienced and dedicated attorneys at Callagy Law are ready to help answer your questions about forming a business or ensuring that your existing business is in compliance with the law. Contact Callagy Law now for legal guidance.

More information on Callagy Law’s Medical Revenue Recovery program click here.

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Pursuing Medical Debt From Insurers | Medical Revenue Recovery